219 Beauchamp Rd `�.-<. �' _ �.�,'c. . I,.-.i—,v ..-,a't.+:m�>1x; .Yit r • p.dwrr.s.�.1 .acv- .r Vri .. -. 4i , s v - -.. . .. .. - -.-. ::•,
- " DAVIE COUNTY HEALTH DEPARTMENT
�`• ra IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION JI as
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal,Rulgs (10 NCAC 10A .1934-.196 ) Permit Number
Name '%rte 7`vPAa�/6 �,+�x �! er��, Date �L� N27 ,
Location ,'cl('T .-��L�, ",✓� � , �:r
Subdivision Name Lot No. Sec. or Block No.
Lot Size 3 A/ House Mobile Home �'�Business Speculation
No. Bedrooms No. Baths _ No. in Family
Garbage Disposal YES p NO fl Specifications for System;
Auto Dish Washer YES NO ❑
Auto Wash Machine YES UJ NO
Type Water Supply
4c.Jf'�
*This permit Void if sewage system described below is not installed within 36,months from date of issue.
.w {
F
i
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8-30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
� S
Certificate of Completion _ Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
2
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ,�,�
11� Environmental Health Section O OCT 17 tacea
1 P. O. Box 665 R�C
Mocksville, N.C.27028
CONSTICI ( LL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Hip
Home Phone
1. Permit Requested By Business Phone n —
2. Address
3. Property Owner ' ifferent tha b ve
Address 3 (�c. 1 8� b
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home 's Business
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms -:�? Bath RoomsDen w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information i orrect to th est of my knowledge.
Date 0 Owner Signatur
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �lr , AZ
fc\,_jc,
DCHD(6-82) 0,
1,/'' r `e ,►.lJC../1 Tv
Davie County Health Department
1 ' ' Environmental Health Section
` Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
M0-� (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the ownerhe aba describe property, however, I certify that I
have consent from owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
ye no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE 0 SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation resu s from the above described property to the following:
— Owner only
r�Owners designated representative
—Anyone requesting results
Only thr listed below
49
1 -13 �
DATE S NATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.G. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size 1 �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
112 ($� (t� 1�p
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) 4P
G Ul,/ U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S- -___. �. __.__ C` PS
U
4) Soil Depth (inches) S S
—".C� qP
U ��
5) Soil Drainage: Internal —dip /11�
S S
U
External _� _._ S
U U U
6) Restrictive Horizons
7) Available Space S
Pt S
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS-7-Provisionally Suitable
Recommendations/Comments:
Described by7 �� Title J��r� Date
SITE DIAGRAM
DCHD(6-82)
Dw e County. Nealtl 7Waiency
artment
l
and .dome .ilea tfi
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE,N.C. 27028
PHONE:(704)634.5985
October 23, 1989
Ricky Styers
c/o Betty Potts Realty
Rt. 3, Box 328
Advance, NC 27006
Re: Site Evaluation
Mocks Church Road
Dear Mr. Styers;
On October 23, 1989, as you requested a representative from this office
visited the above mentioned site. The soil was found provisionally suitable
for the installation of a ground absorption sewage system.
If you have 4ny questions, please feel free to contact this office.
Sincerely,
,�
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure